Advance care planning: Making it easier for patients (and you)

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Applied Evidence

Advance care planning: Making it easier for patients (and you)

J Fam Pract. 2017 August;66(8):487-491

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References

1. Kutner L. Due process of euthanasia: the living will, a proposal. Indiana Law J. 1969;44:539-554.

2. California Law Revision Commission. 2000 Health Care Decisions Law and Revised Power of Attorney Law. Available at: http://www.clrc.ca.gov/pub/Printed-Reports/Pub208.pdf. Accessed May 15, 2017.

3. H.R. 5067 - 101st Congress. Patient Self Determination Act of 1990. Available at: https://www.govtrack.us/congress/bills/101/hr5067. Accessed November 16, 2016

4. The SUPPORT Principle Investigators. A controlled trial to improve care for seriously ill hospitalized patients. The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT). JAMA. 1995;274:1591-1598.

5. Institute of Medicine. Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. Washington, DC: National Academies Press; 2015.

6. Dixon J, Matosevic T, Knapp M. The economic evidence for advance care planning: systematic review of evidence. Palliat Med. 2015;29:869-884.

7. Wright AA, Ray A, Mack JW, et al. Associations between end-of-life discussions, patient mental-health, medical care near death, and caregiver bereavement adjustment. JAMA. 2008;300:1665-1673.

8. Brinkman-Stoppelenburg A, Rietjens JAC, van der Heide A. The effects of advance care planning on end-of-life care: a systematic review. Palliat Med. 2014;28:1000-1025.

9. Detering KM, Hancock AD, Reade MC, et al. The impact of advance care planning on end of life care in elderly patients: randomised controlled trial. BMJ. 2010;340:c1345.

10. Morrison RS, Chichin E, Carter J, et al. The effect of a social work intervention to enhance advance care planning documentation in the nursing home. J Am Geriatr Soc. 2005;53:290-294.

11. Schamp R, Tenkku L. Managed death in a PACE: pathways in present and advance directives. J Am Med Dir Assoc. 2006;7:339-344.

12. Walczak A, Butow PN, Bu S, et al. A systematic review of evidence for end-of-life communication interventions: who do they target, how are they structured and do they work? Patient Educ Couns. 2016;99:3-16.

13. Sudore RL, Fried TR. Redefining the “planning” in advance care planning: preparing for end-of-life decision making. Ann Intern Med. 2010;153:256-261.

14. Straton JB, Wang NY, Meoni LA, et al. Physical functioning, depression, and preferences for treatment at the end of life: the Johns Hopkins Precursors study. J Am Geriatr Soc. 2004;52:577-582.

15. Fried TR, Byers AL, Gallo WT, et al. Prospective study of health status preferences and changes in preferences over time in older adults. Arch Intern Med. 2006;166:890-895.

16. Rao JK, Anderson LA, Lin F, et al. Completion of advance directives among U.S. consumers. Am J Prev Med. 2014;46:65-70.

17. Grudzen CR, Buonocore P, Steinberg J, et al; AAHPM Research Committee Writing Group. Concordance of advance care plans with inpatient directives in the electronic medical record for older patients admitted from the emergency department. J Pain Symptom Manage. 2016;51:647-651.

18. Jones AL, Moss AJ, Harris-Kojetin LD. Use of advance directives in long-term care populations. NCHS Data Brief. 2011;(54):1-8.

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20. Fried TR, Bullock K, Iannone L, et al. Understanding advance care planning as a process of health behavior change. J Am Geriatr Soc. 2009;57:1547-1555.

21. Schickedanz AD, Schillinger D, Landefeld CS, et al. A clinical framework for improving the advance care planning process: start with patients’ self-identified barriers. J Am Geriatr Soc. 2009;57:31-39.

22. Winter L, Parks SM, Diamond JJ. Ask a different question, get a different answer: why living wills are poor guides to care preferences at the end of life. J Pall Med. 2010;13:567-572.

23. Institute of Medicine. Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. Available at: https://www.nap.edu/read/18748/chapter/1. Accessed May 15, 2017.

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28. American College of Physicians. Advanced Care Planning: Implementation for practices. Available at: https://www.acponline.org/system/files/documents/practice-resources/business-resources/payment/advance_care_planning_toolkit.pdf. Accessed May 15, 2017.

How-to tips for advance care planning in the outpatient setting

When approaching the topic of ACP with patients, it’s important to do so over time, starting as soon as possible with older patients and those with chronic illness conferring a high risk of significant morbidity or mortality. Assess each patient’s understanding of ACP and readiness to discuss the topic. Many patients think of ACP in the context of a document (eg, living will), so asking about the existence of a living will may help to start the conversation. Alternatively, consider inquiring about whether the patient has had experience with family or friends at the end of life or during a difficult medical situation, and whether the patient has thought about making personal plans for such a situation.²⁵

When a patient is ready to have this conversation, your goal should be three-fold:²⁶

Help the patient articulate personal values, goals, and preferences.
Ask the patient to formally assign health care power of attorney (POA) to a trusted individual or to name a surrogate decision-maker. Document this decision in the medical record.
Help the patient translate expressed values into specific medical care plans, if applicable.

Because ACP conversations are often time consuming, it’s a good idea to schedule separate appointments to focus on this alone. If, however, a patient is unable to return for a dedicated ACP visit, a first step that can be completed in a reasonably short period would be choosing a surrogate decision-maker.

Helping a patient articulate personal values may be eased by asking, "Have you ever thought about what kind of care you would want if you could not make your own decisions?"

Helping a patient articulate personal values may be eased by asking such questions as: “Have you ever thought about what kind of care you would want if the time came when you could not make your own decisions?” or “What worries you the most about possibly not being able to make your own decisions?”²⁷ If the patient is able to identify a surrogate decision maker before the ACP appointment, ask that this person attend. A family member or close friend may remember instances in which the patient expressed health care preferences, and their presence can help to minimize gaps in communication.

Once the patient’s preferences are clear, document them in the medical record. Some preferences may be suitable for translation into POLST orders or an advance directive, but this is less important than the overall discussion. ACP should be an ongoing conversation, since a patient’s goals may change over time. And encourage the patient to share any desired change in plans with their surrogate decision-maker or update the POA document.

Be sure to bill for advance care planning services

To encourage office-based providers to conduct ACP, CMS implemented payment for CPT codes 99497 and 99498.

CPT code 99497 covers the first 30 minutes of face-to-face time with patients or their family members or medical decision-makers. This time can be used to discuss living wills or advance directives.

CPT code 99498 can be applied to each additional 30 minutes of ACP services. Typically, this billing code would be used as an add-on for a particular diagnosis such as heart failure, chronic obstructive pulmonary disease, or pancreatic cancer.

CPT Code 99497 equates to 2.40 relative-value units (RVU) with an estimated payment of $85.99, while CPT code 99498 equates to 2.09 RVU with an estimated payment of $74.88.²⁸

According to CMS, there is no annual limit to the number of times the ACP codes can be billed for a particular patient. And there are no restrictions regarding location of service, meaning a provider could perform this in an outpatient setting, an inpatient setting, or a long-term care facility. Both physicians and non-physician practitioners are allowed to bill with this code. Also worth noting: You don’t need to complete any particular documentation for a visit to be billed as an ACP service. CMS provides a helpful Q & A at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/FAQ-Advance-Care-Planning.pdf.

CORRESPONDENCE
John Liantonio, MD, Thomas Jefferson University Hospital, Department of Family and Community Medicine, 1015 Walnut Street, Suite 401, Philadelphia, PA 19107; john.liantonio@jefferson.edu